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ADA Diabetes Camp Application – 2012

Dear Parents and Prospective Camper:

Thank you for completing STEP ONE of your online registration process. This is our fifth year launching our nationwide online application process and we appreciate your patience as we get the new year rolling. We hope this online process will make completing camper applications quicker and easier.

THESE FORMS REQUIRE ORIGINAL SIGNATURES, THEREFORE MUST BE COMPLETED AND MAILED TO THE NORTHERN IL OFFICE IN ORDER TO COMPLETE THE APPLICATION PROCESS AND BE

SUBMITTED FOR MEDICAL REVIEW

As instructed, you MUST print and fill out the additional attached camper forms that follow this letter:

o Medical Form/Health Evaluation – completed & signed by diabetes health care provider & returned in a signed/sealed envelope

o Consent Form – signed by parent

o HIPAA Form – signed by parent

o Immunization Form/ Insulin Regimen Form- completed by parent

o Refund Policy – for your information

o Financial Assistance Form – if applicable

o Counselors Form – If applicable

Please make a copy of your supplemental forms before submitting and have your physician make a copy of his/her form. Only complete applications, received with the non-refundable deposit will be submitted to members of the ADA camp committee for review. Incomplete applications will be returned and will not enter the processing system until resubmitted as a complete application. Missing forms, missing information (i.e. immunization information or insurance information) will cause a delay in processing your application.

Once you have completed and mailed the supplemental forms to the ADA office (address below) you may continue filling out the online application.

Priority System: Applications are processed and reviewed on a first come, first serve basis*. Once application forms have been reviewed by members of the ADA Camp Committee, confirmations will be made on a first come, first serve basis. It is critical that you complete all required forms and submit them as soon as possible. The information you provide enables us to adequately prepare for the best week of your child’s summer. Once the application has gone through medical review, and no further information is requested, you will receive a “confirmation packet”.

*First come, first serve is defined as: the date the original forms are returned to the office, complete and ready to process.

Once all camper slots are filled, children will be placed on a waiting list. A waiting list occurs due to limited space and/or securing the required number of medical staff. This waiting list is important so that we can fill camp slots up to the last minute. While many of the children on our waiting list do find a space at camp, we cannot guarantee an opening. You can increase your child’s likelihood of attending camp if the application form and all accompanying materials are submitted as soon as possible.

Payments: If you did not pay both the non-refundable deposit and the remaining camper fee online, full payment must be received at least 3 weeks before the start of camp. If you are in need of financial assistance, you must complete and return the financial assistance form attached with this letter. You will be notified by Sue Apsey, Camp Director, if/when financial assistance is awarded. Please contact her, 312-346-1805, ext. 6567, with any questions you may have regarding your financial assistance application.

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Our camps are organized and operated by the American Diabetes Association (ADA) in conjunction with leading medical and camping professionals in your local community.

Both our day camps and residential camps are accredited by the American Camp Association. This accreditation helps ensure that the ADA provides a safe, medically supervised camping experience for children with diabetes. It is our hope that each child who attends camp will grow as an individual through the ideas and experiences shared through this camping experience.

Opportunities to learn are offered in formal and informal settings. In years past, campers have described their experience at camp as educational and fun! While diabetes camp is not a clinic in the woods, our medical team provides round the clock care at camp for your child with safety as our primary concern. The medical team is fully capable of addressing a child’s blood sugar fluctuations brought on by changes in daily routine and environment. These fluctuations are likely and expected, and should in no way hinder a child from fully participating in the camping experience.

For questions, please contact Megan Johnson at [email protected] or 1-888-DIABETES, ext. 6602.

Mail ALL Forms To:

American Diabetes Association Attn: Megan Johnson55 E. Monroe St., Suite 3420Chicago, IL 60603

Sincerely,

American Diabetes Association Camps

Forms to be returned to the ADA Office:

o Physician’s Form – completed & signed by diabetes health care provider & returned in a signed/sealed envelope

o Counselors Form – If applicable

o Consent Form – signed by parent

o HIPAA Form – signed by parent

o Immunization Form/ Insulin Regimen Form- completed by parent

o Financial Assistance Form – if applicable

o Non Refundable Deposit (if not paid online)

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mailto:[email protected]


PHYSICIAN’S FORMCAMPER’S NAME ________________________________ DATE ____/____/____Please check the appropriate camp sponsored by the American Diabetes Association, Northern Illinois Area.Camp Discovery (Glen Ellyn) [ ] Camp Confidence (Des Plaines) [ ] Camp Can-Do (Palos Park) [ ] Triangle D Camp [ ] Teen Adventure Camp [ ]

1. General Health:Significant illness or physical disability: ________________________________________________________________________________________________________________________________________________Medication(s) other than insulin (with dose & for what?):___________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies (food, medicine, animals, etc. ) if asthma, please indicate severity: ___________________________________________________________________________________________________________________Physical Limitations: _______________________________________________________________________Menarche for girls: Age: _________Non-diabetes hospitalizations (date/diagnosis): __________________________________________________________________________________________________________________________________________2. Has your patient had exposure to any blood transmissible diseases?Yes [ ] No [ ] If so, of what nature? ___________________________________________________

3. Most Recent Exam:Date: ________ Height _______ Weight _________ B/P: ________ HR: ________Skin: ____________________________________________________________________________________HEENT: _________________________________________________________________________________Thorax: _________________________________________________________________________________Abdomen/Genitals: ________________________________________________________________________Neurological: _____________________________________________________________________________

4. Diabetes Management:Year of diagnosis: _______________________Hospitalizations (for diabetes) date & diagnosis: _________________________________________________________________________________________________________________________________________Most recent HbA1c level : ****THIS IS MANDATORY and must have been within the last three months****Date: ____________ Result: __________________ Normal Range for Lab: ___________Current goals of diabetes management: ______________________________________________________________________________________________________________________________________________What meter does the patient use? _________________________________ #Tests/day _________________

Is child/teen on an insulin pump? Brand ______________________________________ How long has child/teen been using the pump? List number of years, months or start date: _______________ Do you anticipate child/teen going on a pump before camp? Yes [ ] No [ ] NOTE: If you anticipate your patient will be placed on a pump prior to the start of camp; please be advised that the camp medical staff requires that the youth be on a pump, using insulin, AT LEAST THREE WEEKS PRIOR TO CAMP.Is camper on a continuous glucose monitoring system? Yes [ ] No [ ] If yes, what system?________________________________________________________________________

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PHYSICIAN’S FORM (PAGE 2)Insulin Types and Dosage: Please list the type and amount of insulin given Home Insulin Regimen: Pump Basal:

Please Indicate Sliding Scale or Bolus Rate Time Rate Time Type Breakfast Lunch Dinner Bedtime

Correction Factor: _____________________________ Insulin/Carb Ratio:

Does the patient or family adjust insulin at home? [ ] Yes [ ] No

Indicate target blood sugar range: _______________________________

Circle Insulin BRAND: Lilly NovoNordisk Sanofi-Aventis Humulin ReliOn Pen: [ ] Yes [ ] NoCircle TYPE: Humalog Novolog Levemir Lantus Apidra Regular NPH Other: ____________________________

Meal Plan: Number of meals per day____ Number of snacks per day____ Insulin for Snacks? ( ) Yes ( ) NoPlease mark what system is used: Carbohydrate Counting [ ] Exchange System [ ]

Carbohydrate Counting is used and taught at camp. Each camper is given an individual meal plan based on the camper’s home meal plan and the camp activity program.5. Emotional Status:It is imperative that the camp medical staff be aware of any family emotional problems which may affect your patient’s health care at camp. Has your patient and/or family been in counseling in the last year? Yes [ ] No [ ]Has your patient been referred for counseling in the last year? Yes [ ] No [ ]If so, what is the nature of the problem? ______________________________________________________6. Do you have any specific suggestions as to the care of your patient while at camp? ______________________________________________________________________________________________________________________________________________________________________________

**For Overnight Camp:Is there any concern about your patient in a remote setting? Yes [ ] No [ ]If yes, please explain. ______________________________________________________________________________________________________________________________________________________________________________

During your patient’s stay at camp, he or she will be monitored as closely as conditions permit. Any necessary alterations in your patient’s diabetes management will be made under the supervision of an attending physician. **For Day Camp:During your patient’s stay at camp, he or she will be monitored as closely as conditions permit. No alterations in management will be made without due consideration by the medical staff. The medical staff consists of experienced nurses and dietitians, under the supervision of a physician member of the Camp Committee of the American Diabetes Association, Northern Illinois Area.

Signed: ____________________________________ Date:________________________________

___________________________________, M.D./D.O. Email:_______________________________ (Please print/type) MD or Office

Address: _____________________________ Phone: (____)_________________________________

_____________________________ Emergency Phone (____)________________________ Please return in a sealed and signed envelope to: PATIENT’S PARENT as soon as possible. Delay in returning this form may jeopardize your patient’s application to camp. Rev.12.11

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Breakfast Lunch Dinner Bedtime


Camper Name___________________________________________________

COUNSELOR/THERAPIST/PSYCHIATRIST FORM

To be completed by camper’s mental health care provider

(If Applicable)To Parent: If your child has been in counseling within the past year, please have the Counselor/Therapist/ Psychiatrist/ Psychologist complete and return this questionnairePlease complete, sign, date and return to: American Diabetes Association

Attention: Camp Director 55 E. Monroe St., Suite 3420 Chicago, IL 60603

Any delay in returning this form may result in your patient being placed on a waiting list.

To Parent: Please complete/sign this box before forwarding to health professional.

Patient’s Name_________________________________________

Patients Date of Birth____________________________________

Parent/Legal Guardian___________________________________

Address_______________________________ _______________ __________

As the parent/legal guardian, I freely give permission to my child’s therapist/counselor to release information pertaining to my child to the American Diabetes Association for their use at Camp or speak with the ADA representative concerning my child’s treatment.

____________________________________ _________________Signature of Parent/Legal Guardian Date

1. How long have you known your patient? _____________________________________

2. Has your patient been compliant in attending appointments? □ Yes □ No

3. Does he/she pose any danger to self or others? □ Yes □ NoIf yes, please explain.

4. Is there any prior history of suicidal ideation or attempt? □ Yes □ No If yes, please explain.

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5. Is your patient on any psychiatric medications? □ Yes □ No If yes, please list the medication(s), strength and dosage:

See Page 2

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6. Please list any specific recommendations that would be helpful in the care of your patient for the Camp medical staff.

7. Are there any reasons that you feel your patient should not participate in the American Diabetes Association summer Camp program? □ Yes □ NoIf yes, please explain.

8. Would you be willing to be contacted, if necessary, by telephone during Camp should a problem arise? □ Yes □ No (This will only be done if absolutely necessary.)

If yes, please include your answering service or home telephone number with area code below.

Phone Number: (______)_____________________

During your patient’s stay at Camp, he/she will be monitored as closely as conditions permit. No alterations in management will be made without due consideration by the medical staff. The medical staff consists of experienced medical, family practice, and pediatric residents, nurses and dietitians, under the direct medical supervision of an attending physician.

_________________________ ___________________________ _______________Please print name Signature Date

Address:___________________________________

___________________________________

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___________________________________ City State Zip

Thank you for your cooperation. If you have any questions or comments, please feel free to call Sue Apsey, Camp Director at 312-346-1805, ext. 6567

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Prospective Camper CONSENT FORM I hereby apply for admission of my child (name) ____________________________ to the summer Camp for children with

diabetes operated by the American Diabetes Association. I understand my child shall be subject to the same Camp rules as the other children at Camp. I consent to my child receiving any and all medical care, treatment and testing the Camp’s health care provider in

charge determines is medically necessary, in his or her sole discretion (including without limitation diet, insulin dosage and/or type 2 oral medication and daily blood glucose monitoring). I consent to my child receiving any other medically necessary medical care, treatment, and testing the Camp diabetes care provider in charge may cause to have performed by a licensed health care provider, emergency medical personnel at any facility, clinic or hospital while my child is a Camp participant, including without limitation tuberculin test and x-ray if the test is positive, and blood testing for Hepatitis B and/or HIV antibodies, in the event of an accidental finger prick where there may be possibly contaminated material (such as a syringe needle or lancet). I agree that I am personally responsible for any and all medical charges and expenses resulting from the treatment of my child either on the Camp property or at an off-site facility and that my insurance, if any, shall be the primary insurance plan.

I further consent to the release of any and all test results to the Public Health Authorities, if such release is required by any law, statute, or regulation.

I freely give permission to my child’s health care providers (including without limitation physicians, physician’s assistants, clinical nurse practitioners, R.N.s, R.D.s, certified diabetes educators, therapists, psychologists, etc.) to release any and all information pertaining to my child to the American Diabetes Association, and any third party health care providers or institutions the American Diabetes Association deem medically necessary to treat my child during the Camp session. This consent expires at the end of the camp session or the last day any necessary paperwork arising from the treatment of my child is complete, whichever date is later, and may be revoked at anytime by giving written notice to the American Diabetes Association

I hereby grant my consent and permission for my child to leave the premises of the camp on occasional trips to nearby points of interest under the supervision of the Camp Staff.

I understand that while the American Diabetes Association may supply insulin, syringes, monitoring supplies and routine first aid care required at Camp, I shall be primarily responsible for the cost of all other medical treatment of my child, including but not limited to laboratory tests, x-rays, and emergency treatment at a hospital or clinic.

I understand that ADA is not responsible for any damage, maintenance, repair or replacement of any durable medical equipment (including insulin pumps, continuous glucose monitors, hearing aids) my child may use during camp, and other risks assumed in the use of such devices

I hereby waive, release and shall indemnify ADA against any and all claims, injury, damages or liability which may arise from my child’s use of any durable medical equipment including without limitation misuse, malfunction or medical care in connection with such durable equipment.

I understand that the purpose of the continuous glucose monitor is to show trends and not to adjust insulin. No alterations in my child’s medical plan will be made based on CGM readings/warnings (alarms) without discussion with and approval of camp medical staff directly responsible for my child’s care.

In order to assist in the prompt treatment of my child, I hereby consent to any necessary medical or surgical treatment and testing of my child of an emergency nature and my child receiving off-site medical care at the closest available medical facility. Below my signature, I have listed the policy number for any applicable policies of hospitalization insurance that I carry on this child (including Medical Assistance). I authorize the appropriate representative of the American Diabetes Association to release the information concerning my hospitalization insurance to any provider of medical or surgical services to my child.

In consideration of the American Diabetes Association allowing my child to attend its summer Camp, I hereby knowingly waive and release the American Diabetes Association, its agents, employees, assigns, volunteers, directors, officers and medical staff, from any and all liability or claim arising out of and in connection with my child’s participation in camp for any reason.

I have read and am aware of and shall abide by the Camper Pick-Up policies.

Please check and initial one of the two following statements:_____ I do consent to the placement of my child’s name, address, phone number and email address in a Camper Directory that is given toInitials each camper.

_____ I do not consent to the placement of my child’s name, address, phone number and email address in a Camper Directory that is given toInitials each camper.

______ Further, I have read, and fully understand and I knowingly agree to the terms of this Consent Form. Initials

_____________________________ ___________ _____________________________ __________8


Signature of Father/ Mother Date Signature of Legal Guardian Date

The following information is for hospital / immediate care center billing purposes only: Insurance Company _______________________Policy Number ___________________ Group Number ______________________ Policy Holder Information: Name ___________________________ Birth Date______________________ SSN__________________Child’s Information: Name _______________________________ Birth Date______________________ SSN__________________

AMERICAN DIABETES ASSOCIATIONAUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION

HIPAA (Health Insurance Portability and Accountability Act)

Camper Name: __________________________________________________________

Camper’s Date of Birth ___________________________________________________

Name of Custodial Parent /Legal Guardian ___________________________________

I hereby authorize the American Diabetes Association (ADA) to release the above named Camper’s Personal Health Information (PHI) as described below:

The purpose of this disclosure is to promote the ADA Camp program, publicize the ADA Camp program, and/or fund-raise for the American Diabetes Association:

The PHI to be disclosed is limited to the following:[ ] Camper photograph or likeness[ ] Other: (specify_______________________)

The PHI may be disclosed as part of the American Diabetes Association’s marketing efforts, including but not limited to, mailing list development for Camp, a brochure promoting Camp or other educational program, or fundraising events of the American Diabetes Association. Expiration date: This Authorization shall expire on December 31, 2022. Right to Revoke: I understand that I have the right to revoke this Authorization at any time by giving ADA written notice of the revocation. I understand that any revocation will not apply to any disclosure that has already been made in reliance upon this authorization.I understand that I have the right to refuse to sign this Authorization and that my refusal will not affect my child’s ability to receive treatment, get payment for treatment, or attend camp. I understand that I will be given a copy of this signed Authorization. A copy of this document is valid as an original. The original is not required to be shown.

_______________________________________ Custodial Parent’s/Legal Guardian’s Name (print)

______________________________________/____________Custodial Parent’s/Legal Guardian’s Signature / Date

_______________________________________ 9


Relationship to Camper

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Immunization History

Please read carefully the options below. Incomplete applications will not be accepted, if you are unsure whether you need to provide a copy of your child’s immunization records, PLEASE INCLUDE IT in your camp application. You will be notified as soon as possible if you do not provide a copy of an immunization record and/or we do not have a complete one on file.

Must be filled out by parent or doctorProvide a copy of the school immunization record if you cannot locate complete

information

VACCINESMonth & Year of Basic

ImmunizationMo. & Yr. of Last

BoosterDiphtheria Pertussis (Whooping Cough) Tetanus or DTaP Tetanus Diphtheria or TD or TDaP (6th grade and older) Tetanus Injectable/Inactivated Polio- (Salk) - IPV Oral Polio (Sabin) - OPV Measles (Hard Measles, Red Measles, Rubella) - MMR Mumps Rubella (German Measles, 3 – Day Measles) Tuberculin Test Given (Most recent) - TB Haemophilus Influenza b (HIB) Hepatitis A: **Please List both shots in series** 1. 2.Hepatitis B: **Please List all 3 shots in series** 1. 2. 3.HVZ Chicken Pox - Varicella Meningitis- High School RecommendedInfluenza (most recent)

Campers Name: __________________________________ Date: _________________________

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Immunization History: Record the date (Month & Year) of Basic Immunizations & most recent Booster doses.


Insulin Regimen

TO BE FILLED OUT BY PARENT

For Syringe or Pen Users ONLY: Insulin /Carbohydrate RegimenInstructions: Please list the type and amount of insulin given Examples: Breakfast 15N & 3H or 15N plus 1 unit Humalog per 10 grams of carbohydrateTotal Calories per dayBreakfastMorning SnackLunchAfternoon SnackDinnerEvening SnackCorrection Factor used for blood sugars above what mg/dl? Example: bs >150Insulin Correction Dose: Units given per mg/dl of blood sugar? Example: 1 unit Humalog for every 50 pointsTotal Daily Carbohydrates

For Pump Users ONLY: Pump Basal Rates: Please enter child’s rate per hour.Midnight 8:00am 4:00pm1:00am 9:00am 5:00pm2:00am 10:00am 6:00pm3:00am 11:00am 7:00pm4:00am Noon 8:00pm5:00am 1:00pm 9:00pm6:00am 2:00pm 10:00pm7:00am 3:00pm 11:00pm

For Pump Users ONLY: Insulin / Carbohydrate Bolus Rates Instructions: Please list the type and amount of insulin given to cover each meal.Example: 1 unit Humalog per 10 grams of carbohydrate or 1H: 10gTotal Calories per dayBreakfastMorning SnackLunchAfternoon SnackDinnerEvening SnackCorrection Factor used for blood sugars above what mg/dl?Example: bs >150 Insulin Correction Dose: Units given per mg/dl of blood sugar? Example: 1 unit Humalog for every 50 pointsTotal Daily Carbohydrates

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Campers Name: __________________________________ Date: _________________________

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Insulin at Mealtimes:

Morning Snack

Type of insulin_________________________________

_______Unit per ______grams of carb or ______carb servings.

Do you give a correction at AM snack? _____Yes or _____No

Correction factor: _____unit for every _____points above _____ or below _____.

Lunch

Type of insulin given____________________________________Below is the scale or amount I normally give my child. Please provide the scale or insulin ratios.

Example: 80-150 0 units Humalog Insulin ratios:150-200 1.0 units Carb bolus: ______units per ______ gms carb200-250 2.0 units Correction: ______units for_______ points

______________________________ above_____ or below______.____________________________________________________________

Afternoon Snack

Type of insulin_________________________________

_______ Unit per ______ grams of carb or ______ carb servings.

Do you give a correction at PM snack? _____ Yes or _____ No

Correction factor: _____ unit for every _____ points above _____ or below _____.

PARENT'S SIGNATURE:_____________________________________________

DATE:___________________________________________

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CAMP REFUND POLICYThe American Diabetes Association strives to control the costs associated with providing camp in order to keep the fee families pay as reasonable as possible. ADA underwrites the cost of every camper by at least 50% of the fee that is charged to families.In order to provide the camp program, ADA must contract and pay for the procurement of staff, a camp facility and all supplies up to 10 months prior to camp. We must pay all expenses for a guaranteed number of campers regardless of the number that actually attend. Therefore, this policy is to ensure that we can continue to make camp affordable for families, continue providing financial assistance to families who need it, and have time to fill vacancies from the camp waiting list. Camp Committee unable to place camper in a session:

Refund of Camp Fee & deposit Camper Cancels after being accepted:

a. Written cancellation received 60 days prior to camp opening dayRefund of Camp Fee less non-refundable deposit

b. Written cancellation received 59 to 30 days prior to camp opening day. Refund of 50% of Camp Fee less non-refundable deposit

c. Written cancellation received 29 to15 day prior to camp opening day:

Refund of 25% of Camp Fee less non-refundable deposit

d. Written cancellation received 14 days or less prior to camp opening day:

No refund of Camp Fee or non-refundable deposit.

e. Serious Illness or death in family: Refund of Camp Fee less non-refundable deposit

Opening Day:a. Camper not accepted due to condition found by camp

physician during camp opening day health screening.Refund of Camp Fee less non-refundable deposit

b. Camper not showing on opening day.15

ADA Diabetes Camp Application – 2012No Refund of Camp Fee or non-refundable deposit

Early Departure of Individual Camper from Camp:

a. Illness during camp; camp physician recommends camper returns home.Refund of Camp Fee prorated less non-refundable deposit

b. Illness during camp; camp physician recommends camper can remain in camp, but parent elects to withdraw camper. No Refund of Camp Fee or non-refundable deposit

c. Serious Illness or death in family, camper removed at parent’s request.Refund of Camp Fee prorated less non-refundable deposit

d. Camper elects to leave camp early (camper homesick; camper wanting to return home for various reasons).No Refund of Camp Fee or non-refundable deposit

e. Camper sent home for reasons determined appropriate for protection of said camper, other campers or staff. No Refund of Camp Fee or non-refundable deposit

Early Closure of Camp because of Shortened Session due to Fire, Epidemic, or Natural Disaster:

a. During the first half of camper session.One-half of camp fee paid will be refunded less non-refundable deposit

b. During the last half of camper session.No Refunds will be made

c. Camp closed prior to session due to above.Refund of camp fee less non-refundable deposit

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Late arrival or camper absence during camp session:No Refund of Camp Fee or non-refundable deposit

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AMERICAN DIABETES ASSOCIATIONFINANCIAL ASSISTANCE APPLICATION

This application must be completed in its entirety. Please attach a copy of your most recent 1040, 1040-A or EZ tax form or copy

of IL Medi-Plan medical card.Mail all information to:

American Diabetes Association55 E. Monroe St., Suite 3420

Chicago, IL 60603Print all information

NAME OF CAMPER: ______________________________________________________________________

ADDRESS: ______________________________________________________________________

CITY: _______________________________ STATE: ____ZIPCODE______________

DATE DIAGNOSED _______________ DATE OF BIRTH _______________

NUMBER OF YEARS CHILD HAS ATTENDED CAMP: ______________

FATHER’S NAME: _____________________________________________________

ADDRESS (if different than camper) ______________________________________________________________________

CITY: _______________________ STATE: ___________ZIPCODE________________

PLACE OF EMPLOYMENT: ______________________________________________________________________

HOME TELEPHONE: _______________ WORK TELEPHONE: _________________

MOTHER’S NAME: ______________________________________________________

ADDRESS (if different than camper) ______________________________________________________________________

CITY: _______________________ STATE: ______________ ZIPCODE___________

PLACE OF EMPLOYMENT: ______________________________________________________________________

HOME TELEPHONE: ________________ WORK TELEPHONE: __________________

Public Aid? ___Yes ___No IL Medi-Plan Case ID # _________________ REQUIRED: Copy of medical card.

Please attach a copy of your 1040, 1040-A or EZ tax form.

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Are there any extenuating or special circumstances that you would like considered when your application is reviewed? (If necessary, please provide information on a separate piece of paper.)

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PAGE 2 AMERICAN DIABETES ASSOCIATION FINANCIAL ASSISTANCE APPLICATION

List other persons living in your household for whom you provide financial support but do not claim on your taxes.NAME RELATIONSHIP AGE STATUS – please circle

TO CAMPER ____________________ ______________ _______ Employed Student Other

____________________ ______________ _______ Employed Student Other



____________________ ______________ ________ Employed Student Other

PLEASE NOTE: This application is not a camp registration form to attend camp. This is to request financial assistance only.

Are you an ADA Member: Yes ______ No _______ If yes, please provide Membership ID number ______________________________________

Deposit included with Reservation Form: Yes _______ No ________

Which camp are you applying for: _________________________________

HAVE YOU SUBMITTED A CAMP APPLICATION FOR THE ABOVE CAMP?YES NO

*Note: You must be registered to apply for financial assistance.

PLEASE STATE THE AMOUNT YOU ARE ABLE TO PAY TOWARDS THE CAMP REGISTRATION FEE: $__________________Residental Camps: $795 Members, $895 Non-MembersDay Camps: $275 Members, $375 Non-Members

You will be notified by your American Diabetes Association as to your request for financial assistance and any amount awarded.

Please attach a copy of your most recent 1040, 1040-A or EZ tax form or IL Medi-Plan medical card.

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